19719APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification -
4ulding Ad'resa: .. c�,
PERMIT NO.
19719
waeraName: Phone:
^m
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /PERMIT
— L
c°^trade .Name: °:
s -
BUILDING-ELECTRICAL-PLUMBING-MFGHAMCAL
CATEGORY CONTROL p
Ash ed/Engineer: Lie, No:
pPERMIT_;FEE
,QTY'P- E�:ECTRID ,, •• ' ,-
-
-"BUILDING PERMIT INFO
Add ns:ere
� • . E D X
PERMITISSUANCE �
LICENSED CONTRACTOR'S DECLARATION
Thereby
Sediffinnthatlam Rceneedtheunder Bugroviaions ndPmfesk=sr9de,and ic-
Beer.hSection 7000)of d dieon3 ofthe BuNneseand ProfnealonaCode,and my
license tal.. to end effect. -
License Class Lic.p -
M['LIANCESRESIDENML
)OB DESCRIPTION
PANELS
_
Date Contractor '3CVf1aCOA
201 -IMO AMPS
ARCHITECTS DECLARATION -
I understand my plane shall be used as public recoils.
OVER 1000 AMPS
SQ, FT. FLOOR AREA
$/SQ. FI.
SIGNS ELECTRICAL
Licensed Professional
SPECIAL CIl2CUIT/MIST
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
TEMP. METER ORPOLE INST.
follow{ng reason.(Section7031.$ Buslnessand Professioe.Codes Anydlyvr
oountywhlchrequiresapermltWcomt ct,alter,improve,demollsh,orrepair
aoystmctuie private its Issuance, also requireatheapplicant forsuch permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractors License Law (Chapter 9(commencing with Soolon 7000) of Divi.
sion 3 of the Business and Pnefesalom CodOmthat he is exempt therefromand
POWERDEVICES*-
,
SWIMMING POOL ELECTRIC
VALUATION
the basis for the alleged exemption. Any violation of Seion 7031.5 by any
applicant fora permit subjects the applicant to a dvi�pena ty of am more than
' OUTLETSSWITCHESFIXTURES
-
NEW RESIDENTIAL ELECTR SQ.FL.
five n1,asownerlofthepro
❑ I, as owner of the property, or my employees with wages thele sok
STORIES
TYPE CONSTRUCTION
compensation, windo the the, ls or d for
is nse
Business
sale (sec. 7044, Buelnnee and Pro(emlone Code:7he Contractors License Law
and Prefer Code: Contraot ctor's Law
-
TOTAL:
'(,I[Y; `i"PLUMBING:PERMIT 'i' ;¢:;FEE
does not apply to an owner of property who builds or Improves thereon, and
who doessuch work himself or through his own employees, provided that such
Improvements are not Intended orolfered forests. If, however,thebuildingor
impro ementise°IdwithlnoneyearolcompldioMthe owner-bu0derwillhave
the burden of proving that he did not build or Improve for purpose ofsaleJ.
u
ct construct the project (See.
conL as owner tr the property, am exclusively contracting with Is Code;
and Code:
.00C. GROUP
RES. ❑MTS
FLOOD ZONE
APN
PERMITISSUANCE
he Contra
not apply tct an owner of property why
apply to an o of property
buil Contractor's impre License on, and
build. or Impmvee thereon, end who contracts for such plviede with a
1511 or(sexemtundPursuant rothe ContractureLkarse¢Law.
u I em exempt under Sx. e & P C for this recon
'ALTER -DRAIN & VENT- WATER (EA)
'. "FEE SLIMMARY.
-BACK FLOW PROTECT. DEVICE
OUTSIDE I ITS
DRAINS FLOOR ROOF, AREA, COND.
FE(TURSPER TRAIT
SANITARY Y N
RECEIPT #
Owner Date
WORKMAN COMPENSATION DECLARATION
❑l hereby affirm that I have a certificate of consent to self -Insure, or
certificate of Workers'Compeneation Insurance cracertifed copy themof(Sec.
Polis Lab C.I _ -
SCI{OOL LAX Y_ N_.
Rte. p
CAS EA. SYSTEM -1 INC.4OUTLETS
PARK FEE Y N
RECEIPT#
GAS F.A.SYSTEM-OVER 4 (FA)
n-
CnCey
tlU1LU1NC DIVISION FEES
ifedpyls hereby furnished.
MCertfiedeopybllled withthe city Inspection dvlala.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(Chia.ecti°n need nut be completed tithe permit Ls fore. hundred dollars
Date Recei t#
"
SEWER -SANITARY -STORM EA. 200FT.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
I co lesJ
(St lo)rtifyt
cehat lathe performance of the work for which this permit is Issued,
WA•I.Qt SYS.IFM/.I.RFA.I.ING -
,
I shall not employ any person In any manner w w t becpme sub ecl,.to the
Workers Com�oeation La�wspf �glif W.D a dJ
Applicant z-/1MOJ.1/I�LI- LQ G
PAID
Date - Rett'1 f#
NEW RESIDENT[AL'PLMB. SQ.HT.
NOTICE TO AIPPUCAN 1: IL a making this Cartl uteof Exemption, you
TOTAL:
shouidbecomesubject to the Wo re'Compertsation provisioroofthe Labor
Code, you must forthwith comply with such provisions orthls permit shall be
deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihembyaffirm that there is a construction lending agency for the perform-
once of the work for which this permit is Issued (Sec. 3097, Civ. CJ
Lendee. Name
Lender's Address
I certifythatl have read thisappllcationand statethattheabove information
b oarrect.I agreeto comply with all city and county ordinances and state lawn
, TOTAL:
ELECTRIC FEE
.•..
MEChANICAU'.PERMITi "',.FE6r
PLUMBING FEE
MECHANICAL FEE
7Lt,CD
PERMITISSUANCE Z„Co
FEES PAID:
relating to building covtructon, and hereby authorize representatives of this
city he enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an of keep baroness the City of Cupen Inv
against liabilities, pdgments,coat. and expenses which may In any way accrue
ALTFRORADDTOMECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
against said City In consequence of the granting of this permit.
-
AIRHANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUST HOOD M/ DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous..
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
I lealth and Safety Code Section 25532(.)7
❑ Yes r] No
Will the applicant or future building occupant use equipment or devices
/y
HEATING UNIT (TO 100,000 BTU) —fs(�o
Date Recei t#'
-
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
I .W
VENTILATION FAN (SINGLE MID)
I$$ ATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qu a Illy Management District? '•
4 Yes No
have rcadthehaza ousmatedal.mquirementsunder Chapter6.95of
- - -�
f n 1990
I•w Ji
BOILER-COMPOHPOR100,00o BTU) '
BOILER-COMP(OVERIWU)
,OW BT
the California Health & SafetyCode, Sedlons 25505, 25533 and 255M. I
understand that if the building does not canently have a tenant, that it is my
to notify the occupant of the requirements which must be met
-Uls{41�n,^f�11!AQ
NEW RESIDENTIAL MECH. SQ.FP.reeponsibility
pnKan//c/�ff�f(j, �ff a Certifies? Occupancy. �
C_L
ISSUED BY:�Nav-#"`-^"�"t
i adthorive n
gen
TOTAL: �.i.C1O
OFFICE COPY